Virginia United Methodist Conference Your Plan: PPO Core $1,000/20% Your Network: KeyCare

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1 Virginia United Methodist Conference Your Plan: PPO Core $1,000/20% Your Network: KeyCare This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This policy has exclusions and limitations to benefits and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact your insurance agent or contact us. If there is a difference between this summary and the contract of coverage, the contract of coverage will prevail. Covered Medical Benefits Overall Deductible See notes section to understand how your deductible works. n $1,000 person / $2,500 family $1,500 person / $3,750 family Out-of-Pocket Limit When you meet your out-of-pocket limit, you will no longer have to pay cost-shares during the remainder of your benefit period. See notes section for additional information regarding your out of pocket maximum. $6,500 person / $13,000 family Preventive care/screening/immunization In-network preventive care is not subject to deductible. $0 copay; 0% coinsurance is met Doctor Home and Office Services Primary care visit to treat an injury or illness $30 copay Specialist care visit $50 copay Prenatal and Post-natal Care Initial visit only. See Inpatient Services for Global delivery benefit $30 or $50 copay Page 1 of 8

2 Covered Medical Benefits Other practitioner visits: n On-line Medical Visit Live Health Online is the preferred telehealth solutions ( $20 copay Chiropractic services Limited to 30 visits per calendar year. Other services in an office: Allergy testing /Treatment Chemo/Radiation therapy Dialysis/Hemodialysis Diagnostic Services Lab: Office /Preferred Reference Lab /Outpatient Hospital X-ray: Office /Freestanding Radiology Center /Outpatient Hospital Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Office /Freestanding Radiology Center /Outpatient Hospital Emergency and Urgent Care Emergency room facility services Paid as In-network Page 2 of 8

3 Covered Medical Benefits Emergency room doctor and other services Ambulance Transportation n Paid as In-network Urgent Care Center Office Visit $50 copay Outpatient Mental Health and Substance Use Disorder Doctor Office Visit and Online (LiveHealth Online) Visit $0 copay; 0% coinsurance Facility visit: Facility fees /Doctor Services $0 copay; 0% coinsurance Outpatient Surgery Facility fees: Hospital Freestanding Surgical Center Doctor and other services Surgery Hospital Stay (all inpatient stays including maternity, mental and substance use disorder) Facility fees (for example, room & board) Doctor and other services Including global maternity fee Page 3 of 8

4 Covered Medical Benefits Recovery & Rehabilitation Home health care Coverage for and combined is limited to 100 visits per calendar year. n Rehabilitation services (for example, physical/speech/occupational therapy): Office /Outpatient hospital No visit limits Cardiac rehabilitation Office Visit Outpatient hospital Skilled nursing care (in a facility) Limited to 100 days per admission. Hospice 0% coinsurance Durable Medical Equipment Prosthetic Devices Vision routine exam Separate vision plan is available for all routine vision exam and materials Not covered Not covered Page 4 of 8

5 Covered Prescription Drug Benefits n Pharmacy Deductible Not applicable Not applicable Pharmacy Out of Pocket Prescription Drug Coverage Anthem National Drug Formulary Member must file claim for out-of-network reimbursment Tier 1 - Typically Generic Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program.) No coverage for non-formulary drugs. Tier 2 - Typically Preferred Brand & Non-Preferred Generics Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program.) No coverage for non-formulary drugs. Tier 3 - Typically Non-Preferred Brand/Specialty (brand/generic) Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program.) No coverage for non-formulary drugs. Combined with medical out of pocket $15 copay per $30 copay per prescription (home $30 copay per $60 copay per prescription (home $50 copay per $100 copay per prescription (home Combined with medical out of pocket $15 copay per No coverage (home $30 copay per No coverage (home $50 copay per No coverage (home Page 5 of 8

6 Notes: The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family member will be applied to the individual deductible and individual out-of-pocket maximum; in addition, amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one member will pay more than the individual deductible and individual out-of-pocket maximum. Your coinsurance, copays and deductible count toward your out of pocket amount. For additional information on this plan, please visit sbc.anthem.com to obtain a "Summary of Benefit Coverage". All medical services subject to a coinsurance are also subject to the annual medical deductible. If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in and out of network. In-network preventive care is not subject to deductible. If your plan includes out of network benefits and you use a non-participating provider, you are responsible for any difference between the covered expense and the actual non-participating providers charge.when receiving care from providers out of network, members may be subject to balance billing in addition to any applicable copayments, coinsurance and/or deductible. This amount does not apply to the out of network out of pocket limit. Human Organ and Tissues Transplants require precertification and are covered as any other service in your summary of benefits. Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Questions: Visit us at Original Contract Code: 39DV/01-19 Page 6 of 8

7 Language Access Services: Get help in your language Curious to know what all this says? We would be too. Here s the English version: If you have any questions about this document, you have the right to get help and information in your language at no cost. To talk to an interpreter, call (833) Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. (TTY/TDD: 711).(833) Armenian (հայերեն). Եթե այս փաստաթղթի հետ կապված հարցեր ունեք, դուք իրավունք ունեք անվճար ստանալ օգնություն և տեղեկատվություն ձեր լեզվով: Թարգմանչի հետ խոսելու համար զանգահարեք հետևյալ հեռախոսահամարով (833) : Chinese( 中文 ): 如果您對本文件有任何疑問, 您有權使用您的語言免費獲得協助和資訊 如需與譯員通話, 請致電 (833) (833) French (Français) : Si vous avez des questions sur ce document, vous avez la possibilité d accéder gratuitement à ces informations et à une aide dans votre langue. Pour parler à un interprète, appelez le (833) Haitian Creole (Kreyòl Ayisyen): Si ou gen nenpòt kesyon sou dokiman sa a, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou gratis. Pou pale ak yon entèprèt, rele (833) Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e informazioni nella sua lingua senza alcun costo aggiuntivo. Per parlare con un interprete, chiami il numero (833) (833) Korean ( 한국어 ): 본문서에대해어떠한문의사항이라도있을경우, 귀하에게는귀하가사용하는언어로무료도움및정보를얻을권리가있습니다. 통역사와이야기하려면 (833) 로문의하십시오. (833) Page 7 of 8

8 Language Access Services: Polish (polski): W przypadku jakichkolwiek pytań związanych z niniejszym dokumentem masz prawo do bezpłatnego uzyskania pomocy oraz informacji w swoim języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer: (833) (833) (833) Spanish (Español): Si tiene preguntas acerca de este documento, tiene derecho a recibir ayuda e información en su idioma, sin costos. Para hablar con un intérprete, llame al (833) Tagalog (Tagalog): Kung mayroon kang anumang katanungan tungkol sa dokumentong ito, may karapatan kang humingi ng tulong at impormasyon sa iyong wika nang walang bayad. Makipag-usap sa isang tagapagpaliwanag, tawagan ang (833) Vietnamese (Tiếng Việt): Nếu quý vị có bất kỳ thắc mắc nào về tài liệu này, quý vị có quyền nhận sự trợ giúp và thông tin bằng ngôn ngữ của quý vị hoàn toàn miễn phí. Để trao đổi với một thông dịch viên, hãy gọi (833) It s important we treat you fairly That s why we follow federal civil rights laws in our health programs and activities. We don t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C or by calling (TDD: ) or online at Complaint forms are available at Page 8 of 8